Provider Demographics
NPI:1346587631
Name:BARUCH, KELLI M (DPT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:M
Last Name:BARUCH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:M
Other - Last Name:CROUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:12465 LEWIS STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4658
Mailing Address - Country:US
Mailing Address - Phone:714-703-8477
Mailing Address - Fax:714-703-8157
Practice Address - Street 1:12465 LEWIS STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4658
Practice Address - Country:US
Practice Address - Phone:714-703-8477
Practice Address - Fax:714-703-8157
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39615225100000X
CAPT396152251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist